Provider Demographics
NPI:1104846849
Name:RUSSO, PETER ANTHONY (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ANTHONY
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18800 MAIN ST
Mailing Address - Street 2:STE. 201
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1707
Mailing Address - Country:US
Mailing Address - Phone:714-842-2515
Mailing Address - Fax:714-847-7075
Practice Address - Street 1:18800 MAIN ST
Practice Address - Street 2:STE. 201
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1707
Practice Address - Country:US
Practice Address - Phone:714-842-2515
Practice Address - Fax:714-847-7075
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA411271223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics